AC759 - 29ft from worst aviation crash in history

[Astro14]

Originally Posted By: Driz
It was a [censored] good thing it wasn't a foggy [censored] night or it likely would have actually happened. It just amazes me though how in the world on a clear night those guys couldn't tell blue lights from white ones, particularly with the strobes going and position lights of all those planes plastered all over the area they were going to touch down. The only possible explanation would be that there were so many close in and background lights that everything appeared mixed together. . Still, in spite of any of it there's that little matter of the ILS strobes running off to the side and not directly in front of their path. No matter how you cut it that flight crew wasn't paying attention during the most critical phase of flight.


No.

Just no.

In the fog, the airplane would be coupled. It wouldn't be lined up in the taxiway.

How many SFO night landings do you have as the pilot of an airliner? Just wondering how you're able to accurately and fairly judge their performance...

 

[Astro14]

Originally Posted By: Win
Originally Posted By: Astro14
But AC 759 was already going around, or they would've crashed. The controller issued those instructions well after the critical point at which a crash could've been averted.

ATC is not infallible.

How much time / distance does it take to stop the sink and establish a positive rate of climb? How much power can they keep up and for how long while on approach?


On approach, the engines on almost every modern airliner are spooled up enough (approach idle setting, FADEC, etc.) to respond in a few seconds. Allow two seconds for reaction time, plus that spool up, and at a typical approach sink rate (call it 700 FPM) you'll lose about 50 feet.

Since the glideslope intersects the runway about 1,500 from the approach end - if the crew of Air Canada had continued the approach, they would've hit all the airplanes on the taxiway, including the United 787. Since they overflew united at about 100 feet, they must have initiated the go around before they overflew any of the runway - the threshold crossing height on the ILS is 55'. So, it was the crew that made the mistake, but it seems it was the crew that prevented disaster by correcting it, with a bit of help from the United crew that saw them lined up wrong.

Further, what approach were they flying? The FMS visual does NOT line you up with the runway.




Only the ILS lines you up with the runway, but as I said, Bay Approach doesn't like using the ILS, they like to leave you high, and fast, and off centerline, and then placing all the burden on the crew with a visual.

The ILS would place you on centerline.

 

[turtlevette]

[Quote astro]

How many SFO night landings do you have as the pilot of an airliner? Just wondering how you're able to accurately and fairly judge their performance...

[/quote]

I don't think we need any landings or takeoffs or level flight or any of it to feel uncomfortable. We're bull short. And have a right to be.

That collision in the canary islands makes me really mad. There was no need to stage planes like that in the fog. Just foolhardy. Leave one at a time. What's the rush? You've been sitting for hours anyway.

 

[plaguef]

Originally Posted By: CT8
There wasn't a crash though.

 

[Al]

Originally Posted By: plaguef
Originally Posted By: CT8
There wasn't a crash though.

Every time you drive along an undivided highway you are 3 feet away from crashing into an oncoming vehicle. Happens millions of times/day. Statistics are usually your friend and so it was with AC759. Move along folks..nothing to see here

 

[turtlevette]

Originally Posted By: Al
Originally Posted By: plaguef
Originally Posted By: CT8
There wasn't a crash though.

Every time you drive along an undivided highway you are 3 feet away from crashing into an oncoming vehicle. Happens millions of times/day. Statistics are usually your friend and so it was with AC759. Move along folks..nothing to see here


And you worked at a nuke plant. Just gives one warm fuzzies all over.

 

[Wolf359]

Originally Posted By: turtlevette
Originally Posted By: Al
Originally Posted By: plaguef
Originally Posted By: CT8
There wasn't a crash though.

Every time you drive along an undivided highway you are 3 feet away from crashing into an oncoming vehicle. Happens millions of times/day. Statistics are usually your friend and so it was with AC759. Move along folks..nothing to see here


And you worked at a nuke plant. Just gives one warm fuzzies all over.



Yep, we're always inches, feet from death every day.

 

[Win]

Thank you for posting those plates, Astro.

 

[Astro14]

You're welcome, Win - though not easy to read, they do provide some background/context to the discussion.

I've been flying in/out of SFO for 20 years now. It's just a challenging airport, I know I said that, but the combination of terrain, runway spacing (very close), frequent bad weather, an approach control system that leaves pilots in an untenable position and, in this case, lack of familiarity, all lead to an easily-made mistake.

The key to safety in aviation is error management. Complex environment, high performance,machines, human interaction, all lead to mistakes. There is no perfect pilot. No perfect flight.

The true professionals are the ones who recognize their own errors, correct them, and diligently try to improve each time. I can promise you that Air Canada pilots will be analyzing this error in detail, incorporating the lessons learned into therir training and SOP.

The real question I am left with is: using my above criteria, will Bay Approach and SFO Tower act like true professionals?

Will they analyze and absorb the lessons here?

Or will it continue to be business as usual at SFO?

 

[zuluplus30]

Originally Posted By: Astro14
The real question I am left with is: using my above criteria, will Bay Approach and SFO Tower act like true professionals?

Will they analyze and absorb the lessons here?

Or will it continue to be business as usual at SFO?


Care to shed more light on this statement? The folks at NorCal TRACON and SFO tower are some of the best in the business.

 

[Astro14]

Originally Posted By: zuluplus30
Originally Posted By: Astro14
The real question I am left with is: using my above criteria, will Bay Approach and SFO Tower act like true professionals?

Will they analyze and absorb the lessons here?

Or will it continue to be business as usual at SFO?


Care to shed more light on this statement? The folks at NorCal TRACON and SFO tower are some of the best in the business.


Define "best".

"Maintain visual separation (from the RJ NOW BEHIND YOU)" - uh...OK...

"Maintain 180 to the bridge, cleared the visual" - when you're 3,000 feet, and over the San Mateo bridge, 6 miles from touchdown...good luck. Virtual guarantee of an unstable approach.

I've been at 11,000 feet, heading 100, 280 KIAS assigned, and abeam the airport - "cleared the visual 28R - start your turn now"

Seriously???

Lose 11,000' in a few miles? From 280 KIAS (which is clean in most airplanes)? Start the turn now?

That's the best?

That is creating a problem and expecting the pilots to solve it. High, fast, cleared the visual. That's their M.O. They don't call it the "San Fran Slam Dunk" for nothing.

Sure, tower times departures and arrivals well on intersecting runways, but they were heads down during this Air Canada approach by their own admission. And so, despite their joint responsibility for safety, chose to take their eyes off the airplanes.

So, will they examine their role in this incident?

Did they change anything after Asiana 214's crash?

SFO is considered special qual. You have to meet special qualifications to fly in there.

And then they added unique approaches (LDA, SOIA, Offset visual) to accommodate both traffic flow and, this is key, noise abatement. They don't want you lined up, or on a normal glideslope, because the folks who live near the airport complain about noise.

So, make the approach visual, non-conforming, and you don't have to be in normal parameters. Put the burden on the crews to solve the alignment and energy problems.

 

[turtlevette]

When you say "take their eyes off airplanes" , do you mean actually looking thru the window or on the screen? Is there enough resolution on the radar to do that?

I started looking into this and it lead to listening to conversations on youtube. Its alarming how stressed out the controllers are. Makes me not want to ever fly again.

I get its a fraternity and pilots support pilots no matter what. As an independent uneducated observer what you suggest puts even more responsibility and stress on the shoulders of controllers. So maybe we need to train and hire a lot more. Listening, these guys give instructions every few seconds and it never stops. I'd lose my mind and flip out after an hour.

 

[L_Sludger]

Originally Posted By: turtlevette

I get its a fraternity and pilots support pilots no matter what.

Erm, it's more like an association. An Air Line Pilots Association, if you will. Phrasing.

 

[Andrew1972]

On a side note there is chatter and lets say likely some related tweet to privatize the ATC........

 

[PimTac]

I have had a number of flights out of SFO and always try to watch the pattern from the mezzanine level on the A concourse. The timing is fascinating to watch.

 

[Vikas]

I am surprised that Astro has made ZERO comment about the pilot lining up his jet on the taxiway instead of on the runway.

Isn't the crew in best position to see their own approach vs the ATC who is not in position to ascertain if the plane has lined up correctly or not? ATC was telling him correctly that the runway was open for him.

I am not getting why Astro is blaming ATC here instead of putting the blame squarely on the pilot.

 

[Vikas]

Astro expects us to believe that ATC should have been able to notice that aircraft was lined up to land on the taxiway and that is their responsibility and is even taking potshots at ATC as he insinuating that they were doing facebook on their phones.

Really really shameful.

 

[cjcride]

Originally Posted By: Vikas
I am surprised that Astro has made ZERO comment about the pilot lining up his jet on the taxiway instead of on the runway.

Isn't the crew in best position to see their own approach vs the ATC who is not in position to ascertain if the plane has lined up correctly or not? ATC was telling him correctly that the runway was open for him.

I am not getting why Astro is blaming ATC here instead of putting the blame squarely on the pilot.

The way I read it Astro is stating it is shared responsibility. Plus other factors not encountered at most airport approaches.

 

[L_Sludger]

And an airline pilot has a ton of other things going on in the cockpit as well. Delegating many tasks is part and parcel of the golden practice of CRM (Crew Resource Management) as it is practiced today in flight operations.

 

[Win]

The way I read it, the aircrew making a mistake is a symptom of a bigger problem.

The way I read it, the problem is an arbitrary, perhaps dubious, objective of reducing noise in Palo Alto, San Carlos, etc., that is keeping aircraft too high to bleed energy and safely descend in the allowed distances, pushing air traffic off against a rapidly rising ridge instead of over flatter land, making them do complex visual approaches over open water at night, instead of using the installed expensive and highly reliable electronic navigation systems that make aviation safe, and would prevent the mistake in the first place.

And despite fatalities occuring, arguably flawed procedures are still in place, and more fatalities could occur until they are changed.

That's the way I read it, anyway.